2012_0523 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW PREVENTION ASSEA�LY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE
The bacldlow prevmtioa assembly detailed below has been tested and ma;nrained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacurzm Breaker
^_ Double Check Valve � Atmosphere Vacuum Breaks
Manufactrrrs
Model Number
Serial Number
Size
Located At
The above is certified to be true_
Firm Name
Gauge #
Date last accuracy tested
Certified Tests
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAT�'R
Double Chec3c Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Islet
Cheek Valve
Initial Test
DC- Closed
Tight �
Closed Tight II
Leaked o
Opined at
nsid
Opined at
nsid
nsid
RP- nsid
1„eaked a
Did not Opm o
Leaked �
Repairs
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight �
Closed Tight o
Opined at
nsid
Opened at
nsid
nsid
RP sid
The above is certified to be true_
Firm Name
Gauge #
Date last accuracy tested
Certified Tests
Cent Tester No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy